Rates and types of events reported to established incident reporting systems in two US hospitals

Abstract

Background: US hospitals have had voluntary incident reporting systems for many years, but the effectiveness of these systems is unknown. To facilitate substantial improvements in patient safety, the systems should capture incidents reflecting the spectrum of adverse events that are known to occur in hospitals. Objective: To characterise the incidents from established voluntary hospital reporting systems. Design: Observational study examining about 1000 reports of hospitalised patients at each of two hospitals. Patients and setting: 16 575 randomly selected patients from an academic and a community hospital in the US in 2001. Main outcome measures: Rates of incidents reported per hospitalised patient and characteristics of reported incidents. Results: 9% of patients had at least one reported incident; 17 incidents were reported per 1000 patient-days in hospital. Nurses filed 89% of reports, physicians 1.9% and other providers 8.9%. The most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers. Qualitative examination of reports indicated that very few involved prescribing errors or high-risk procedures. Conclusions: Hospital reporting systems receive many reports, but capture a spectrum of incidents that differs from the adverse events known to occur in hospitals, thereby substantially underdetecting physician incidents, particularly those involving operations, high-risk procedures and prescribing errors. Increasing the reporting of physician incidents will be essential to enhance the effectiveness of hospital reporting systems; therefore, barriers to reporting such incidents must be minimised.

Doctors’ experiences of adverse events in secondary care: the professional and personal impact

“…[3][4][5][6][7][8][9][10] Many clinicians are also reluctant to disclose details of adverse events (see Box 1) to patients and their families. 11,12 Multiple factors are thought to contribute to this, including the psychological effects on clinicians of involvement in adverse patient safety events, a fear by them that their organisation will take a punitive approach to any investigation, and a lack of confi dence that systems will change as a result of reporting.…”

Patient safety with reference to the occurrence of adverse events in admitted patients on the basis of incident reporting in a tertiary care hospital in North India

“…Number of studies showed a measurable percentage of adverse events reported with respect to the total admission taken place. 4,5 In our study, the patient/family dissatisfaction with care received, documented or expressed during the current admission was the most common incident reported. Hospital acquired infection/sepsis being the second most common incident reported in admitted patients.…”

“…In contrast to our study nurses, allied health professionals and doctors were the persons reporting any adverse event happening in a patient. 4,7,8,10,11 In our study adverse events presented with untoward outcome, with 34.8% causing admission in wards, 24.6% causing unexpected death, 28.6% causing disability at the time of discharge and 48.7% causing prolonged stay. Similarly in other studies untoward outcome presented as death or permanent loss of function, permanent lessening of function, additional surgery or increased length of stay.…”

“…In contrast to our study, hospital-incurred patient accident or fall, Medication errors, procedural variances, hospitalacquired infections and sepsis were most common incidents reported. [4][5][6][7][8][9] In our study incidents were mainly reported by patient and their attendants, followed by the treating physician and nursing staff. In contrast to our study nurses, allied health professionals and doctors were the persons reporting any adverse event happening in a patient.…”

Review article: The influence of psychology and human factors on education in anesthesiology

“…A system that reviews adverse outcomes or near misses can identify latent factors before a major disaster takes place, but the system will enhance safety only if those with influence engage in it. 45 Important as engagement is, change is more likely to occur if those analyzing the near misses or adverse outcomes use the language of human factors to facilitate comprehension of the interaction between the practitioners and their environment.…”